Discussion
Management of right-sided IE affecting the TV includes medical versus
surgical management, with intravenous antibiotics as the cornerstone
treatment for this condition. 3 However, surgical
intervention, such as valve replacement, valve repair, and valvectomy
may be warranted in several situations including persistent infection,
large valve vegetations, and right-sided heart failure secondary to
severe TV regurgitation. 3 Despite similar survival
outcomes, valve repair is preferred to valve replacement due to freedom
from reoperation and lower pacemaker implantation. 3Due to concerns about developing right-sided heart failure and its
association with in-hospital stroke, renal failure, and mechanical
ventilation, valvectomy has been recommended as a bridge to valve repair
or replacement. 4
Despite its risks, valvectomy may be an appropriate intervention in
patients with persistent sepsis, extensive lesions, and abscess.3 A staged valvectomy before valve replacement has
also been recommended in patients with ongoing drug use with concerns
for inconsistent follow-up and poor IVDU abstinence. This gives
providers time to manage addiction and other psychosocial morbidities
before valve replacement. 5 Valvectomy is generally
contraindicated in patients with pulmonary hypertension and right-sided
heart failure due to severe tricuspid regurgitation. 5Despite the existence of this contraindication in our patient, we
pursued valvectomy to get source control of the persistent infection.
Concomitant arterial-venous ECMO helped with right-sided decompression
and optimizing systemic perfusion.
While not common practice, urgent ECMO can be used as a bridge to
diagnosis and corrective surgery in patients who develop comp
licationspost tricuspid valvectomy. In one case, an undiagnosed or newly
developed PFO in the patient resulted in right to left shunting and
subsequent refractory hypoxemia post tricuspid valvectomy.6 ECMO gave providers time to diagnose the PFO on
imaging and appropriately prepare patients for corrective surgery. In
our case, ECMO was a planned procedure, allowing the clearance of
bacteremia and preventing further complications from VSD and right-sided
heart failure in preparation for definitive management.
High-risk repeat surgery for endocarditis secondary to IVDU recidivism
is an ethically controversial topic. As recidivism is the leading cause
of mortality in patients who undergo surgical management, some providers
consider repeat surgery psychosocially futile. 2,7 As
follows, strategies such as the “three-strike approach” have been
proposed. This is a contract in which the patient agrees to appropriate
follow-up and addiction management with only two chances of surgical
interventions. Others believe that because prosthetic valves, unlike
donor organs, are not a scarce resource, healthcare professionals should
not limit treatments on the basis of patient adherence to lifestyle
recommendations. 8 Our institution does not restrict
the number of reoperations for recurrent prosthetic valve endocarditis,
as long as they are surgical candidates from an operative risk
standpoint. Furthermore with a multidisciplinary IVDU Addiction Team in
place, consisting of addiction medicine physicians, social workers,
infectious disease physicians, psychiatrists, cardiac surgeons,
nutritionists, pain service specialists, physical therapists, and
cardiologists, our postoperative follow-up success continues to improve.
Therefore, this has allowed us to not refrain from helping patients with
IVDU recidivism. On follow-up care 2 months later, our patient was in
rehab and remained asymptomatic.